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As African countries strive to meet the UN Millennium Development Goals (MDGs) by 2015 and plot a new development agenda thereafter, health experts are gathering evidence across the continent to make a case for a greater focus on its millions of mentally ill.

Experts say investing in mental health treatment for African countries would bolster development across the continent, but national health priorities have been overtaken by the existing MDG structure, which has specific targets for diseases like malaria and HIV, placing them higher on countries’ agendas than other health issues.

“Everyone is putting their money in HIV, reproductive health, malaria,” says Sheila Ndyanabangi, director of mental health at Uganda’s Ministry of Health. “They need also to remember these unfunded priorities like mental health are cross-cutting, and are also affecting the performance of those other programmes like HIV and the rest.”

Global experts celebrated the passing of a World Health Assembly action plan on World Mental Health Day in May, calling it a landmark step in addressing a staggering global disparity: The World Health Organization (WHO) estimates 75-85 percent of people with severe mental disorders receive no treatment in low- and middle-income countries, compared to 35-50 percent in high-income countries. The action plan outlines four broad targets, for member states to: update their policies and laws on mental health; integrate mental health care into community-based settings; integrate awareness and prevention of mental health disorders; and strengthen evidence-based research.

In order for the plan to be implemented, both governments and donors will need to increase their focus on mental health issues. As it stands, the US Agency for International Development (USAID), the world’s biggest bilateral donor, will only support mental health if it is under another MDG health priority such as HIV/AIDS. Meanwhile, mental health receives on average 1 percent of health budgets in sub-Saharan Africa despite the WHO estimate that it carries 13 percent of the global burden of disease.

“Mental health hasn’t found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond,” Harry Minas, a psychiatrist on the WHO International Expert Panel on Mental Health and Substance Abuse and director of the expert coalition Movement for Global Mental Health, told IRIN. “Unless we collectively do something much more effective about NCDs [non-communicable diseases], national economies are going to be bankrupted by the health budgets.”

According to a May report from the UN Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, the MDGs have overseen the fastest reduction of poverty in human history. Yet it also acknowledges that they have done little to reach the world’s most vulnerable. The report says the MDGs were “silent on the devastating effects of conflict and violence on development” and focused too heavily on individual programmes instead of collaborating between sectors, resulting in a largely disjointed approach to health. Experts say without a more holistic approach to global health in the new development era, the world’s most vulnerable will only be trapped in that cycle.

“The MDGs were essentially a set of vertical programmes which were essentially in competition with each other for resources and for attention,” said Minas. “We’ve gone beyond that, and now understand we’re dealing with complex systems, where all of the important issues are very closely interrelated.”

Poverty and Mental Illness

In Africa, where many countries are dealing with current or recent emergencies, WHO sees opportunities to build better mental health care.

“The surge of aid [that usually follows an emergency]combined with sudden, focused attention on the mental health of the population, creates unparalleled opportunities to transform mental health care for the long term,” say the authors of the report Building Back Better: Sustainable Mental Health Care after Emergencies, released earlier this month.

In a study published in the Journal of Affective Disorders in July, researchers in northern Uganda – which, starting in the late 1980s suffered a two-decade long war between the government and the rebel Lords’ Resistance Army – monitored the impact of group counselling on vulnerable groups such as victims of sexual and domestic violence, HIV-infected populations, and former abductees of the civil war. It found that those groups who engaged in group counselling were able to return and function markedly faster than those who did not receive counselling, while reducing their risks of developing long-term psychiatric conditions.

“We need to be mentally healthy to get out of poverty,” Ethel Mpungu, the study’s lead researcher, told IRIN.

The link between mental illness and persisting poverty is being made the world over. According to a 2011 World Economic Forum report, NCDs will cost the global economy more than US$30 trillion by 2030, with mental health conditions alone costing an additional $16 trillion over the same time span.

“It really is around issues of development and economics – those things can no longer be ignored,” says Minas. “They are now so clear that ministries of health all around the place are starting to think about how they are going to develop their mental health programmes.”

Putting mental health on the agenda

As mental health legislation is hard to come by in most African countries, Uganda is ahead of most on the continent with its comprehensive National Policy on Mental, Neurological and Substance Use Services, drafted in 2010. The bill would update its colonial era Mental Treatment Act, which has not been revised since 1964, and bring the country in line with international standards, but is still waiting to be reviewed by cabinet and be voted into law.

Uganda is also part of a consortium of research institutions and health ministries (alongside Ethiopia, India, Nepal and South Africa) leading the developing world on mental health care. PRIME – the programme for improving mental health care – was formed in 2011 to support the scale-up of mental health services in developing countries, and is currently running a series of pilot projects to measure their impact on primary healthcare systems in low-income settings.

Research shows that low- and middle-income countries can successfully provide mental health services at a lower cost through, among other strategies, easing detection and diagnosis procedures, the use of non-specialist health workers and the integration of mental healthcare into primary healthcare systems.

Although a number of projects have shown success in working with existing government structures to ultimately integrate mental health into primary health care, the scaling up of such initiatives is being hindered by a lack of investment, as the funding of African health systems is still largely seen through donor priorities, which have been focused elsewhere.

“Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria,” said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. “But if people don’t care whether they live or die, they’re not going to be able to take advantage of these things that are offered.”

September 2013:
As African countries strive to meet the UN Millennium Development Goals (MDGs) by 2015 and plot a new development agenda thereafter, health experts are gathering evidence across the continent to make a case for a greater focus on its millions of mentally ill.

Experts say investing in mental health treatment for African countries would bolster development across the continent, but national health priorities have been overtaken by the existing MDG structure, which has specific targets for diseases like malaria and HIV, placing them higher on countries’ agendas than other health issues.

“Everyone is putting their money in HIV, reproductive health, malaria,” says Sheila Ndyanabangi, director of mental health at Uganda’s Ministry of Health. “They need also to remember these unfunded priorities like mental health are cross-cutting, and are also affecting the performance of those other programmes like HIV and the rest.”

Global experts celebrated the passing of a World Health Assembly action plan on World Mental Health Day in May, calling it a landmark step in addressing a staggering global disparity: The World Health Organization (WHO) estimates 75-85 percent of people with severe mental disorders receive no treatment in low- and middle-income countries, compared to 35-50 percent in high-income countries. The action plan outlines four broad targets, for member states to: update their policies and laws on mental health; integrate mental health care into community-based settings; integrate awareness and prevention of mental health disorders; and strengthen evidence-based research.

In order for the plan to be implemented, both governments and donors will need to increase their focus on mental health issues. As it stands, the US Agency for International Development (USAID), the world’s biggest bilateral donor, will only support mental health if it is under another MDG health priority such as HIV/AIDS. Meanwhile, mental health receives on average 1 percent of health budgets in sub-Saharan Africa despite the WHO estimate that it carries 13 percent of the global burden of disease.

“Mental health hasn’t found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond,” Harry Minas, a psychiatrist on the WHO International Expert Panel on Mental Health and Substance Abuse and director of the expert coalition Movement for Global Mental Health, told IRIN. “Unless we collectively do something much more effective about NCDs [non-communicable diseases], national economies are going to be bankrupted by the health budgets.”

According to a May report from the UN Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, the MDGs have overseen the fastest reduction of poverty in human history.

Yet it also acknowledges that they have done little to reach the world’s most vulnerable. The report says the MDGs were “silent on the devastating effects of conflict and violence on development” and focused too heavily on individual programmes instead of collaborating between sectors, resulting in a largely disjointed approach to health. Experts say without a more holistic approach to global health in the new development era, the world’s most vulnerable will only be trapped in that cycle.

“The MDGs were essentially a set of vertical programmes which were essentially in competition with each other for resources and for attention,” said Minas. “We’ve gone beyond that, and now understand we’re dealing with complex systems, where all of the important issues are very closely interrelated.”

In Africa, where many countries are dealing with current or recent emergencies, WHO sees opportunities to build better mental health care.

“The surge of aid [that usually follows an emergency]combined with sudden, focused attention on the mental health of the population, creates unparalleled opportunities to transform mental health care for the long term,” say the authors of the report Building Back Better: Sustainable Mental Health Care after Emergencies, released earlier this month.

In a study published in the Journal of Affective Disorders in July, researchers in northern Uganda – which, starting in the late 1980s suffered a two-decade long war between the government and the rebel Lords’ Resistance Army – monitored the impact of group counselling on vulnerable groups such as victims of sexual and domestic violence, HIV-infected populations, and former abductees of the civil war. It found that those groups who engaged in group counselling were able to return and function markedly faster than those who did not receive counselling, while reducing their risks of developing long-term psychiatric conditions.

“We need to be mentally healthy to get out of poverty,” Ethel Mpungu, the study’s lead researcher, told IRIN.

The link between mental illness and persisting poverty is being made the world over. According to a 2011 World Economic Forum report, NCDs will cost the global economy more than US$30 trillion by 2030, with mental health conditions alone costing an additional $16 trillion over the same time span.

“It really is around issues of development and economics – those things can no longer be ignored,” says Minas. “They are now so clear that ministries of health all around the place are starting to think about how they are going to develop their mental health programmes.”

As mental health legislation is hard to come by in most African countries, Uganda is ahead of most on the continent with its comprehensive National Policy on Mental, Neurological and Substance Use Services, drafted in 2010. The bill would update its colonial era Mental Treatment Act, which has not been revised since 1964, and bring the country in line with international standards, but is still waiting to be reviewed by cabinet and be voted into law.

Uganda is also part of a consortium of research institutions and health ministries (alongside Ethiopia, India, Nepal and South Africa) leading the developing world on mental health care. PRIME – the programme for improving mental health care – was formed in 2011 to support the scale-up of mental health services in developing countries, and is currently running a series of pilot projects to measure their impact on primary healthcare systems in low-income settings.

Research shows that low- and middle-income countries can successfully provide mental health services at a lower cost through, among other strategies, easing detection and diagnosis procedures, the use of non-specialist health workers and the integration of mental healthcare into primary healthcare systems.

Although a number of projects have shown success in working with existing government structures to ultimately integrate mental health into primary health care, the scaling up of such initiatives is being hindered by a lack of investment, as the funding of African health systems is still largely seen through donor priorities, which have been focused elsewhere.

“Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria,” said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. “But if people don’t care whether they live or die, they’re not going to be able to take advantage of these things that are offered.”

Syria 13 Nov 2013:The The largest-ever immunization campaign in the Middle East is under-way to stop an outbreak of polio in Syria from spreading throughout the region.

In mid-October, 22 suspected cases of polio were detected in north east Syria. The virus has left 10 children paralysed. But U.N. health agencies warn hundreds of thousands of children across the region are at risk of contracting this crippling disease.

Now, The World Health Organization and U.N. children’s agency are joining forces to immunize more than 20 million children in seven countries and territories during the coming six months.

WHO Polio Eradication Program Spokeswoman Sona Bari notes the virus has been circulating in the region for some time, notably in Egypt, Israel and the West Bank and Gaza. But she says the outbreak in Syria, a country that had been polio-free for 14 years, has accelerated this emergency response in the region.

Bari says emergency immunization campaigns to prevent transmission of polio and other preventable diseases have vaccinated more than 650,000 children in Syria. She says this includes 116,000 in the highly contested north-east Deir-ez Zor province where the polio outbreak was confirmed a week ago.

According to Bari the campaigns fanning out throughout the region aim to vaccinate 22 million children.

“This is a sustained six-month effort. There will be repeated campaigns over this period of time. It is going to need quite an intense period of activity to raise the immunity in a region that has been ravaged both by conflict in some parts, but also by large population movements. So, the virus is moving throughout the region,” she said.

The WHO reports in the past few days, nearly 19,000 children under age five in Jordan’s Zaatari refugee camp have been vaccinated against polio. And, it says a nationwide campaign is currently under way to reach 3.5 million people with polio, measles, and rubella. It says a vaccination campaign has started in western Iraq and soon will begin in the Kurdistan region. Lebanon, Turkey and Egypt also plan campaigns this month.

The polio virus usually infects children in unsanitary conditions through faecal-oral transmission. It attacks the nerves and can kill or cause paralysis. There is no cure for polio, but it can be prevented through immunization.

Bari says 12 suspected cases of polio are under investigation. She says preliminary evidence indicates the polio virus circulating in the region is of Pakistani origin.

There have been media reports that Pakistani fighters brought the polio virus into Syria but the WHO spokeswoman said that is unlikely.

“We are never going to know exactly how it arrived in Syria. What we do know is that we have seen a virus that is very similar in Egypt, in the West Bank and Gaza, and in Israel over the past 12 months. We also know that adults tend to have a much higher level of immunity already developed. So, it is unlikely that adults brought this in. It is probably more likely some other route. But, we will never really know for sure. All we can say for certain is that it is of Pakistani origin and that it has been in this region for a little while,” she said.

Pakistan, Nigeria and Afghanistan are the last three endemic countries in the world, so it is from there that polio will continue to spread. Since WHO began its polio eradication campaign in 1988, vaccination has reduced this crippling disease by more than 99 percent globally.

Despite this setback, Bari says the World Health Organization remains optimistic the outbreak can be stopped and polio, eventually, will be eradicated.

12 September 2013
Geneva — The Special Representative of the U.N. Secretary-General for Children and Armed Conflict has said millions of children caught in armed conflict are victims of grave violations and subject to sexual violence and recruitment as child soldiers. The findings were made in a report that Leila Zerrougui has submitted to the U.N. Human Rights Council.

All people caught in situations of conflict suffer, but children suffer the most, said Zerrougui, who added that many are killed and maimed. and often forced to witness and commit atrocities. Children are also arrested, detained, tortured and ill-treated for their alleged association with parties to conflict, she said.

Zerrougui reviewed the condition of children caught in armed conflict between June 2013 and July 2013 in Syria, Chad, Yemen, the Philippines and other nations at war. Of all the countries under review, she said Somalia remains the one with the largest number of children associated with armed groups.

“The relapse into conflict in Central African Republic and Eastern DRC [Democratic Republic of Congo] has affected the most vulnerable, and children previously separated from armed groups and forces have been re-recruited,” Zerrougui said.

“Reports on the situation in these countries describe a continuing and alarming trend of grave violations committed against children. Children also bore the brunt of the conflict [that] broke out in northern Mali, where armed groups have recruited and used hundreds of children.”

Myanmar 15 May 2013 – Former rebel fighter Lahpai Hkam has been in pain every day since a landmine destroyed his lower right leg during a battle with government soldiers 18 months ago in Myanmar’s northern Kachin State.

“The artificial leg that I was given last year doesn’t fit properly and it rubs on my stump causing a lot of pain,” he said in a hospital in Laiza, the de facto capital of the Kachin Independence Organization (KIO), the political wing of the Kachin Independence Army (KIA), which has been fighting for greater autonomy from the Burmese government for the past six decades.

According to rebel Kachin surgeon Brang Sawng, such stories are common and the number of landmine injuries is on the rise.

“More than 45 soldiers who have had amputations because of landmines over the last two years urgently need prosthetics and replacements,” said Sawng. “The number one injury is caused by landmines, with both Burmese troops and Kachin soldiers mistakenly stepping on their own mines.”

While neither side has published any official figures on civilian landmine casualties, media reports and information from NGOs indicate there were at least 381 landmine casualties, including 84 deaths in 2011. However, international experts say the real number could be significantly higher.

“No armed group – neither the army nor any ethnic armed group [in Myanmar] – provides any public information on casualties, especially civilian ones. This is not unusual,” Yeshua Moser-Puangsuwan, a researcher with the International Campaign to Ban Landmines (ICBL), told IRIN.

Many observers fear a rise in civilian casualties – and prosthetics are not the only thing in short supply.

“For many of the operations we need blood transfusions, but we have no emergency blood bank or reserve so we are forced to operate without blood replacement,” the doctor Brang Sawng explained outside the recovery room of Laiza’s main military hospital.

According to a recent report by Human Rights Watch (HRW), both government troops and the KIA still use landmines.

“These are weapons that will continue to maim and kill for years to come and I would be surprised if both sides are capable of mapping and following where they actually placed these mines,” said Phil Robertson, deputy director of HRW’s Asia division. “The answer is for both sides to cease using anti-personal landmines.”
The collapse of a 17-year-old ceasefire between the Burmese government and the KIA in June 2011, has left more than 80,000 displaced.

For Kachin farmers like Naw Tarong, who fled his home more than a year ago with his wife and three children, leaving behind crops and cattle, the chances of returning home soon look remote.

“We cannot return home because KIA soldiers have planted landmines around our village to keep the Burmese out, and they have warned us not to go back yet,” Naw Tarong said, adding that some of his cattle had stepped on them and been killed.

ICBL’s Moser-Puangsuwan said many civilians (mainly subsistence farmers) set off the mines while returning to their fields or foraging in the forest. “Combatants in Myanmar/Burma do not generally mark their mined areas… A deadly hazard exists.”

Currently, Myanmar has no specific policy to support landmine victims during treatment and rehabilitation, and emergency services in conflict areas are “extremely limited”, according to a 2012 Landmine Monitor report.

As of 1 October 2012, 160 countries (over 80 percent of the world’s governments) have ratified or acceded to the Mine Ban Treaty, and 111 have signed or ratified the Convention on Cluster Munitions. Myanmar has signed up to neither.

MOGADISHU, 26 April 2013 – Lul Mohamed, director of the paediatric ward at Banadir Hospital in the Somali capital, Mogadishu, treated five children after two bomb attacks killed 30 people on 14 April. “And they were shooting last night. One died, a bullet in his liver,” she said of an eight-year-old boy.

Yet these are conditions of relative peace in Mogadishu. While the conflict is not over, insecurity has diminished since the withdrawal of insurgent group Al-Shabab in 2011. This relative security is allowing Mohamed to focus on preventative healthcare, a luxury she did not have two years ago.

In March 2013, she admitted 26 cases with measles, 19 with tuberculosis, 14 with tetanus and nine with meningitis. She is frustrated because all of these diseases are immunizable. Six of the children admitted that month died.

Mohamed hopes this year to immunize 1,000 children per month in the hospital’s tiny but brightly painted vaccination room. Two volunteers sit at a desk, another monitors those coming in and out. They say they became volunteers when donors pulled out and staff were let go. By 1pm that day, they had vaccinated 28 children.

“A huge improvement in a short time – if peace holds,” Mohamed said.

Vaccination

Coinciding with World Immunization Week, the Somali government announced on 24 April its intention to vaccinate all children under the age of one with a new five-in-one vaccine, known as a pentavalent vaccine, funded by the GAVI Alliance, with the UN Children’s Fund (UNICEF) and the UN World Health Organization (WHO) as implementing partners.

“Children in Somalia are dying of diseases that are prevented in the rest of the world,” said Maryam Qasim, the Minister of Development and Social Affairs, speaking at the vaccine’s launch. “Introducing this vaccine is a milestone in history.”

President of Somalia Hassan Sheikh Mohamud also presided over the launch, showing unprecedented support for improving child and maternal health in Somalia, two of the eight UN Millennium Development Goals. He also announced that his government would consider co-financing the vaccination programme, as other countries do, in the future.

Currently, fewer than half of children in Somalia have received the mandatory diphtheria, tetanus and pertussis (DTP) vaccine, a rate that Anne Zeindl-Cronin, senior programme manager at the GAVI Alliance, describes as “incredibly low”. Only 7 percent of children in Puntland and 11 percent of children in Somaliland receive the required three doses by their first birthday, according to a joint UNICEF and government survey.

The pentavalent will protect immunized children against these three diseases, as well as heptatitis B and Haemophilius influenzae type b.

Health system strengthening

“Coming from such a low base, if we have system strengthening, we should see a huge improvement in a short time – if peace holds,” Zeindl-Cronin said.

The pentavalent has taken 18 months to go from the country’s decision to use it to implementation, but she recognizes that GAVI’s implementing partners still have a difficult task ahead. “It’s easy to come here and put [the vaccines] in [a] fridge. It’s getting them into the children that’s the challenge.”

There is not a great deal of infrastructure to rely on. Somalia has suffered close to 25 years of civil war. Its health system is fragmented, supported by an unregulated pharmaceutical industry and dominated by private practitioners who offer help only to those who can afford it. Private doctors in Somalia are earning up to US$10,000 per month.

A legal framework for healthcare is absent, and the federal state, which includes the semi-autonomous regions Somaliland and Puntland, raises questions about how any system might be structured.

“Normally, there is one food and drug administration. But where? Is it in Mogadishu? Or in each of the zones [south-central Somalia, Somaliland and Puntland]?” said Marthe Everard, WHO’s representative for Somalia.

In addition to the systemic and infrastructural challenges of delivering healthcare in Somalia, large areas of the country are still controlled by Al-Shabab; others are inaccessible due to armed groups that have filled the vacuum left by Al-Shabab. Omar Saleh of WHO estimates that 30-40 percent of southern Somalia is accessible to external healthcare providers at any one time.

Risk persists

In his speech at the pentavalent launch, President Mohamud condemned Al-Shabab for blocking access: “In the certain areas they control, there have been no vaccinations at all in the past few years. Al-Shabab needs to understand that they are not only killing people through explosions, but every child that misses vaccinations they have practically killed.”

The pentavalent vaccine launch is being accompanied by an awareness-raising campaign. Sikander Khan, UNICEF Somalia Representative, hopes that, once demand is created, the vaccine will reach women even in areas that Al-Shabab controls. “There is no parent in the world who doesn’t care about the well-being of their child,” he said.

F[ourtesyarhiyo Mohamed, who has six children, brought her youngest to an outpatient clinic in Benadir, Mogadishu, to receive the pentavalent at no cost. The mother says she visited the clinic when Al-Shabab was still in the city, but that it was dangerous to do so. “Al-Shabab would question you when you came back. Today, we are happy,” she said.

While prospects are improving, inequitable access remains a major challenge. Paediatrician Mohamed, at Benadir Hospital, calls for a three-pronged commitment, not only from the government, but also the community and health workers. She says motivating and engaging private and public sector workers is critical to improving the reach of healthcare, and the reach of vaccines in particular.

5 April – Landmines in Myanmar’s south eastern Kayin and Kayah states and Bago division, and in the northern Shan and Kachin states, threaten the return of more than 450,000 refugees and internally displaced persons (IDPs).

“There will be no active promotion of return until landmines areas are identified, openly marked and cleared,” said Maja Lazic, senior protection officer at the UN Refugee Agency (UNHCR) in Myanmar.

While the exact extent of landmine pollution throughout Myanmar is unknown, the army and at least 17 non-state armed groups (NSAGs) have used anti personnel mines in conflicts over the past 14 years, according to the Geneva-based International Campaign to Ban Landmines (ICBL). Myanmar’s central government faces a number of long standing ethnic-based insurgencies by groups demanding greater autonomy.

“Anti-personnel mines are used as terror weapons by both sides… [Some] are not marked because the combatants want to strike fear into the enemy. This results in both sides terrorizing the [civilian] population with mines,” said Yeshua Moser-Puangsuwan, ICBL’s research coordinator for Myanmar. The decline of active conflict in south eastern Myanmar in the past year has led to a slight decrease in reported incidents of mine accidents, according to the ICBL and Geneva Call, a Swiss NGO that specializes in mine-risk education. But no armed group has yet officially committed to ending mine use, said Moser-Puangsuwan.

Mine clearance cannot take place until there is durable peace, say the UN and NGOs. Meanwhile, unreliable information about the location of mines continues to kill, restrict villagers’ movement and stall preparation for the return of displaced populations.

Peace process

The government has signed ceasefire agreements with five NSAGs since January 2012, but trust and collaboration between the various NSAGs and government forces – preconditions for mine removal – are still needed, according to the UNHCR Myanmar.

“The process requires agreement, cooperation and support from conflict parties,” said Lazic and Patricia Treimer, a field officer with UNHCR Myanmar.

The ceasefires have not significantly reduced the use of landmines, as NSAGs, government forces and even civilians continue to employ landmines to defend and reclaim territories and protect themselves.

A spokesperson for the Karen Human Rights Group (KHRG), which authored a May 2012 report on landmines in the east, said that in Kayin State “the ongoing presence of [military] troops means that even though there is a ceasefire, communities and armed groups still take defensive measures, including the planting of landmines”.

Active conflict since June 2011 in Kachin State has displaced upwards of 83,000 people from Kachin and parts of neighbouring Shan. All those displaced are at risk of landmine injuries upon their return, say aid workers.

“[Landmine] incidents have been reported in many regions of Kachin where there has been active fighting,” said Carine Jaquet, the head of the UNHCR’s Myitkyina field office.

Fighting has decreased in recent months in Kachin (with ongoing skirmishes in Shan), but “people are in danger once they attempt to return to their villages,” she added.

“Before the IDPs have a chance to return back, there has to be humanitarian mine action, a security guarantee from both sides and durable peace,” said La Rip, the coordinator of the Laiza-based Relief Action Network for IDPs and Refugees, a network of 12 NGOs providing relief to displaced persons in both government and rebel-controlled areas.

Fears of casualty spike

No mine mapping has been conducted in mine-riddled southeastern Myanmar. Signs marking mined locations are rare and local knowledge about landmines is unreliable, resulting in the frequent landmine incidents, say experts. But it can be even worse for those who have been away.

“Refugees have not had to live with mine risk concerns for many years now, so their awareness of the risks is much lower [than those who stayed],” explained Sally Thompson, executive director of The Border Consortium (TBC), an NGO consortium providing aid to Burmese refugees in Thailand.

Many cross-border routes into southeastern Myanmar are known by locals and NGOs to be contaminated with mines, according to Geneva Call.

Nine refugee camps along the Thai-Burmese border urgently need more mine-risk education, said TBC. “People will be moving as soon as they feel armed conflict has really ended, and we expect there will be a spike in mine casualties as a result,” Moser-Pangsuwan said.

Because peace processes and mine clearance may take years, education is the most practical way of decreasing accidents, according to TBC.

Mine action plans underway

Humanitarian agencies clearing mines, including the UN Children’s Fund (UNICEF) and Danish Church Aid, have been working with the government since November 2012 on mine issues.

The first Mine Risk Working Group meeting in Myanmar was held in January in the capital, Nay Pyi Taw, with UNICEF, Danish Church Aid, the Department of Social Welfare, and the Ministry of Social Welfare, Relief and Resettlement.

“All of the agencies are ready to begin demining activities but are waiting for the government and armed groups to reach an agreement,” said Chris Rush, senior programme officer for Geneva Call in Asia.

In addition, the Myanmar Peace Centre, a government initiative established last October, includes the Myanmar Mine Action Centre, which is currently developing removal standards.

“There is a real push to clear mines, but it is not sensible without understanding where the problem is,” said Rush.

The Myanmar government is among the 20 percent of all governments that have not signed the 1997 Mine Ban Treaty. Along with Syria, it is the only country whose official forces continue to plant mines, according to Moser-Puangsuwan.

“Landmines are one issue, of many issues, affecting return for the displaced. The first measure is an agreement between government and armed groups to stop laying landmines,” said Thompson.